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NELA: more than just another audit

November saw the publication of the fourth NELA report, presenting the outcomes and care processes of approximately 24,000 patients who underwent emergency laparotomy (bowel surgery) between December 2016 and November 2017. NELA is more than just another audit. It represents the hard work undertaken by local teams to provide one of the largest sources of information about the care provided for emergency laparotomy patients in England and Wales. The report characterises the drive and commitment of those looking after these high risk patients.

The findings in the fourth report are encouraging. Enhanced care of these patients has led to the national 30-day mortality rate falling from 11.8 per cent to 9.5 per cent over the last four years.

This represents approximately 700 patients’ lives saved in 2018 compared to 2013. More consultants than ever before are caring for these most high risk of patients and more of them are receiving the expected standards of care, more of the time.

The fourth NELA report included six overarching key recommendations for the care of patients undergoing emergency laparotomy surgery, these were:

improving outcomes and reducing complications

ensuring all patients receive an assessment of their risk of death

delivering care within agreed timeframes for all patients

enabling consultant input in the perioperative period for all high risk patients

effective multidisciplinary working

supporting quality improvement.

Encompassing all the recommendations is the importance of reviewing and using local hospital data and sharing that with everyone across the NHS involved in delivering patient care – not just clinical staff but executive teams too. It is heartening to see that the processes and standards of care that can influence clinicians – such as consultants being present for high risk cases, the review of patients before their surgery and assessing risks, continue to steadily improve. However, those processes that are hard to influence due to a lack of infrastructure and financing (such as being able to get a patient to theatre in time during the day, or admitting all high risk patients to critical care, or provide a comprehensive geriatric input) are less likely to have improved. In other words, the macro-systems clinicians are working within are potentially slowing the improvements to the care they are striving to deliver.

So what next for emergency laparotomy patients? How can the recommendations provided by a national audit really be used by local teams to influence changing care for the better? Clinicians can present hospital level data to the holders of purse strings in hospital trusts as evidence of where resources need to be directed if outcomes are to improve further. Presenting data on length of stay, or readmissions to critical care can be shaped around the financial incentive for hospitals to improve these things – money talks, and sometimes, sadly, this language may be more readily understood than improving outcomes. These findings can be used by local teams – to support the big challenges such as providing a geriatric team, more critical care availability, or to support and streamline smaller (but no less important) processes such as writing a care pathway for the multidisciplinary team. Both the ‘big stuff’ and the smaller details will cumulatively have an influence on the outcomes in improving patient care and helping to save lives.

A recent survey of the College’s NELA leads across England and Wales revealed that many do not have dedicated time within their job plan to perform their role. In addition, some do not have the support of quality improvement /Audit teams. This lack of time is no doubt multifactorial. In these financially constrained times, with increasing pressures on an already stretched service, consultants are simply not being afforded the ability to allocate time to perform this kind of non-clinical work. However, this fails to recognise the need to do more than simply deliver a service. It’s also about improving processes because within health organisations that are lauded as successes; quality improvement and clinical leadership are usually at the very heart of their successes.